Editorial - (2015) Volume 1, Issue 3
1Department of Neuroscience, Psychiatry Unit, University of Parma, Parma, Italy
2Mental Health Department, AUSL, Parma, Italy
*Corresponding Author:
Carlo Marchesi Università
di Parma, Department of Neuroscience, Psychiatry Unit, General Hospital, Braga Building Via Gramsci 14, 43126 Parma, Italy
E-mail: carlo.marchesi@unipr.it
Received Date:: November, 18 2015, Accepted Date:: November 20, 2015, Published Date:: November 30, 2015
Citation: Marchesi C . How useful is the Construct of Alexithymia for Understanding the Risk of Mental Disorders. Acta Psychopathol. 2015, 1:23.doi: 10.4172/2469-6676.100023
Alexithymia is a multidimensional construct characterized by an impoverished fantasy life, a difficulty in expressing or naming feelings, a difficulty in distinguishing between bodily sensations and feelings, and a preoccupation with external events. Alexithymia is considered a risk factor for the development of several mental disorders, such as major depression, panic disorder, eating disorders and substance use disorders.
The TAS-20 is the most widely studied self-report questionnaire used to assess alexithymia. Several studies support the hypothesis that the TAS-20 is overly sensitive to a general distress syndrome, and therefore it is more likely to measure negative effects (distress, nervousness, fear, anger, guilt, sadness, scornfulness) rather than alexithymia itself. Future studies investigating alexithymia among psychiatric populations should control for the severity of anxiety and depression before arguing that alexithymia is a personality trait predisposing to mental disorders. Finally, any study’s finding, based only on a self-reported measure of alexithymia, should be confirmed by clinician-administered questionnaires.
Introduction
The term Alexithymia identifies a multidimensional cognitive and affective condition, characterized by difficulty to recognize and distinguish feelings from bodily sensations of emotional arousal, difficulty to describe emotions, poor fantasies and preoccupation with external events [1]. Alexithymia was originally described as a personality trait in psychosomatic patients with poor response to psychotherapy [2]. More recently, it became a trans-nosographic construct, representing a putative risk factor for the development of several mental disorders, such as major depression (MD) [1], panic disorder (PD) [3], eating disorders (ED) [4] and substance use disorders (SUD) [5].
The TAS-20 [6] is the most widely used and studied self-report measure of alexithymia. Factor analysis has supported a threefactor solution for this scale: (1) difficulty identifying feelings (DIF); (2) difficulty communicating and describing feelings (DDF); and (3) external-oriented thinking (EOT). Items representing impoverished fantasy or reduced daydreaming were dropped from the TAS-20 based on the factor analysis.
In major depression (MD) the rate of alexithymia ranges between 45-46% during the acute phase of illness [7,8]. A similar rate of alexithymia (29-44%) was found in the active phase of panic disorder (PD) [3,9], and even higher rates were observed in patients with eating disorders (ED) (23-77%) [10] and substance use disorders (SUD) (i.e., between 45 and 67% of patients with alcohol use disorders) [11].
However, the evaluation of alexithymia with the TAS-20 can be limited by the fact that alexithymia cannot be validly assessed by a self-report instrument because people with alexithymia, by definition, should not be able to report their psychological state.
Further, when alexithymia was assessed with the TAS-20, significant relationships have been found with depression and anxiety both in the general population [12,13] and in clinical samples. In the general population, depressive symptoms explained almost 36% of the variance of alexithymic features [12] and were significantly correlated with all alexithymic dimensions (DIF: r=0.52; DDF: r=0.42; EOT: r=0.20) [13].
In clinical samples, some studies observed a decrease in the TAS- 20 scores with the improvement of symptoms in MD [7,8,14] or PD [3]. Moreover, an overlap between of TAS-20 (particularly the DIF dimension) and anxiety was found in a factor analysis study in patients with anxiety or depressive disorders [15], and an association between alexithymia and severity of depression and anxiety was also found in SUD [16] and in ED [4,10].
Altogether the aforementioned findings raise the question whether the TAS-20 measures negative affects rather than alexithymia itself in mental disorder.
Several influential authors [1,8,17] suggested that alexithymia is a personality trait which, as such, is characterized by a relative stability: while alexithymic levels can increase and decrease depending on the fluctuation of illness symptoms, the relative differences among individuals remain stable over time. This hypothesis implies that the basic personality conditions, which constitute a liability toward a mental disorder, are accentuated by the state of illness and return to the pre-existing conditions after remission. Nevertheless, the relative stability does not provide any information regarding the pre-morbid alexithymic levels in patients with mental disorders and then it cannot represent a conclusive finding supporting the hypothesis of alexithymia as personality trait. Mikolajczak and Luminet, two authors supporting the trait hypothesis, [18] claimed that “the stability of alexithymia scores at follow-up would not constitute evidence that alexithymia preceded mental disorder”.
Hoffart [26] and Lumley [27] suggested that if the TAS-20 identifies alexithymic personality traits the differences between patients and healthy controls should persist after controlling for anxiety and depression. When this method was applied [21] the differences on TAS-20 total score observed among patients with MD, PD, ED or SUD (all reporting higher scores) and healthy controls disappeared. This finding suggests that the severity of anxious and depressive symptoms could account for the increase of TAS-20 scores observed in patients with mental disorders: when the differences in symptoms severity were controlled for, all patient groups, regardless of their disorder, showed TAS-20 total scores comparable to those reported by healthy controls.
Interestingly, two prospective studies [14,22], investigated alexithymia before, the onset of depressive or a panic episode. These studies found that in women who developed a depressive or a panic episode the premorbid levels of alexithymia were similar to those of healthy subjects. Moreover, in depressed or anxious women alexithymic levels significantly increased during the active phase of the disorders and significantly decrease after 2 months, on average, after remission.All together these data suggest that alexithymia, measured with TAS-20 does not represent a personality trait that increases the risk to develop a depressive or a panic episode and they do not support the hypothesis that alexithymia behaves as a stable personality trait among patients with psychiatric disorders. On the contrary, these data indicate that alexithymia, as assessed by the TAS-20, is a state phenomenon, because its levels appear to be modulated by the severity of symptoms. Moreover, the study of Marchesi et al [21] does not support the notion that TAS-20 scores increase the risk for anxiety and depression as suggested by some authors [23,24]. In fact, they observed that difference between patients and controls in anxious and depressive psychopathology persisted after controlling for the effect of TAS- 20 scores, suggesting that TAS-20 levels do not influence the severity of anxious and depressive symptoms.
There are at least two alternative explanations for the observed relationship between alexithymia, measured with the TAS-20, and anxiety and depression. Alexithymia may be a temporary response to a stressful condition, such as an illness episode; in this view “secondary alexithymia” can represent a defense or a strategy to cope with distress (emotional pain, aversive memories and physiological arousal) associated with a mental disorder [15]. In the second hypothesis, the relationship between alexithymia and depression may represent an artifact of the method and measures used [20], since, particularly, the TAS-20 dimensions DIF and DDF are associated with different measures of negative affects [3,4,10,12,14,15,21,22]. Therefore, individuals with negative emotional states (i.e. anxiety and depression) might score higher on these TAS-20 dimensions.
Thus, several studies confirm the shortcomings of TAS-20, specifically regarding its validity and reliability, in the assessment of alexithymia in clinical samples [25,26]: alexithymia, as assessed by the TAS-20, can be more a measure of negative affect rather than a measure of deficit in the cognitive processing of emotions across different mental disorders. This seems particularly true for the DIF and DDF dimensions, as DIF gauges anxiety symptoms and DDF is sensible to depressive ones.
Conclusion
Several studies support the hypothesis that the TAS-20, the most widely used self-administered scale assessing alexithymia, is overly sensitive to a general distress syndrome, and therefore it is more likely to measure negative effects (distress, nervousness, fear, anger, guilt, sadness, scornfulness) rather than alexithymia itself. Future studies investigating alexithymia among psychiatric populations should control for the severity of anxiety and depression before arguing that alexithymia is a personality trait predisposing to mental disorders. Finally, the findings of the studies, based only on a self-reported measure of alexithymia, need to be confirmed by researches using on observer ratings (e.g., Toronto Structured Interview for Alexithymia) or objective performance-based tasks such as the Levels of Emotional Awareness Scale.
